+Modelfrom http://www.elsevier.es, day 07/11/2018. This copy is for personal use.

Any transmission of this document by any media or format is strictly prohibited.

Document downloaded
BJPT-145; No. of Pages 9 ARTICLE IN PRESS
Brazilian Journal of Physical Therapy 2018;xxx(xx):xxx---xxx

Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy

SYSTEMATIC REVIEW

The effectiveness of dry needling for patients with

orofacial pain associated with temporomandibular
dysfunction: a systematic review and meta-analysis
Clécio Vier a , Marina Barbosa de Almeida b , Marcos Lisboa Neves a ,
Adair Roberto Soares dos Santos a , Marcelo Anderson Bracht a,b,∗

a
Department of Neuroscience, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
b
Department of Physical Therapy, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil

Received 23 January 2018; received in revised form 1 August 2018; accepted 7 August 2018

KEYWORDS Abstract
Dry needling; Background: Orofacial pain of myofascial origin is often associated with temporomandibular
Orofacial pain; joint dysfunction, affects chewing muscles and may lead to functional limitations. Dry needling
Temporomandibular is an intervention commonly used for inactivating myofascial pain trigger points.
disorder; Objective: To systematically review the effects of dry needling on orofacial pain of myofascial
Myofascial pain; origin in patients with temporomandibular joint dysfunction.
Trigger point Methods: This systematic review has pain intensity as primary outcome. Searches were con-
ducted on April 13th, 2018 in eight databases, without publication date restrictions. We selected
randomized controlled trials published in English, Portuguese, or Spanish, with no restrictions
regarding subject ethnicity, age or sex.
Results: Seven trials were considered eligible. There was discrepancy among dry needling treat-
ment protocols. Meta-analysis showed that dry needling is better than other interventions for
pain intensity as well as than sham therapy on pressure pain threshold, but there is very low-
quality evidence and a small effect size. There were no statistically significant differences in
other outcomes.
Conclusion: Clinicians can use dry needling for the treatment of temporomandibular joint dys-
function, nevertheless, due the low quality of evidence and high risk of bias of some included
studies, larger and low risk of bias trials are needed to assess the effects of dry needling on
orofacial pain associated with temporomandibular joint dysfunction.
© 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
Editora Ltda. All rights reserved.

∗ Corresponding author at: Departamento de Fisioterapia, Centro das Ciências do Esporte e da Saúde --- CEFID, Rua Pascoal Simone, 358,

Coqueiros, CEP: 88030350, Florianópolis, SC, Brazil.

E-mail: mabracht@gmail.com (M.A. Bracht).
https://doi.org/10.1016/j.bjpt.2018.08.008
1413-3555/© 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
 +Model
Document downloaded
ARTICLE IN PRESS
from http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
BJPT-145; No. of Pages 9
2 C. Vier et al.
Introduction
Orofacial pain is a condition that affects both the soft and
mineralized tissue of the oral cavity and face.1 Myofascial
pain is the second most recurrent type of orofacial pain, it is
estimated that 33% of people have symptoms in the face and
chewing muscles.1 This condition is frequently associated
with temporomandibular joint dysfunction (TMD), which also
involves chewing muscles, periauricular area and related
structures.2 The incidence of TMD in the United States is
estimated in 3.9% per year,3 and the prevalence of pain
related TMD in the Brazilian population is 25.6%.2
It is generally assumed that myofascial pain related to
TMD4 may originate from trigger points (TP), which are cha-
racterized by hypersensitivity of a palpable nodule or taut
band and pain due to local muscle contraction, which can
reduce range of motion.5
The treatment of myofascial pain is often based on inac-
tivating the TP,6 and therefore, a number of non-invasive
methods have been used, including ischemic compression,
passive stretching, transcutaneous electrostimulation nerve
stimulation, massage, biofeedback, ultrasound, infrared
laser, and cognitive behavioral therapy.7,8
In addition to these methods, a minimally invasive tech-
nique called dry needling (DN) has been developed in recent
decades.7 DN involves applying sterile monofilament nee-
dles that penetrate the skin and muscles, stimulating points
underlying the TP region in order to regulate neuromuscular
pain and movement deficits.1
Despite the widespread use of DN, there is no conclu-
sive evidence of its effectiveness for treating orofacial pain
related to the chewing muscles.9 We aimed to systematically
review to investigate the effects of DN on orofacial pain of
myofascial origin in patients with TMD.
Methods
To summarize the evidence about DN and orofacial pain,
a systematic review of randomized controlled trials was
conducted. We followed the recommendations of Cochrane
Handbook for Systematic Reviews of Interventions10 as
well as the tutorial of systematic reviews of the Brazil-
ian Journal of Physical Therapy.11 This systematic review
was prospectively registered on the PROSPERO database
(CRD42017048449).
Eligibility criteria
To be considered eligible for this systematic review, the
studies had to be randomized controlled trials comparing
DN with placebo/sham therapy or other interventions, pub-
lished in English, Spanish or Portuguese, and had to address
the effects of DN on orofacial pain of myofascial pain ori-
gin, without restrictions on publication date or on subject
age, sex or ethnicity. Exclusion criteria included acupunc-
ture or wet needling in the intervention group, the inclusion
of subjects with neurologic, rheumatic, vascular, metabolic
or neoplastic diseases or the involvement of surgical proce-
dures in the orofacial region.
Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
Search strategy
The search was conducted on April 13th, 2018 in MEDLINE
(via Pubmed), LILACS (via BVS), CINAHL (via EBSCO), Physio-
therapy Evidence Database (PEDro), The Cochrane Central
Register of Controlled Trials (by using Cochrane CENTRAL),
SCOPUS, Web of Science and ProQuest.
Initially, a search was performed in Pubmed using the
following search strategy: ((((((acup*) OR needles[MeSH
Terms]) OR dry needling) AND facial pain[MeSH Terms])
OR temporomandibular joint disorder[MeSH Terms])
OR trigger points[MeSH Terms]) OR myofascial pain
syndrome[MeSH Terms] AND (randomized controlled
trial[Publication Type] OR (randomized[Title/Abstract] AND
controlled[Title/Abstract] AND trial[Title/Abstract])). After
this trial, the search strategy was deemed adequate for use
in the other databases.
Study selection
In order to identify potentially eligible studies, two review-
ers (MBA and MLN) independently selected the articles.
After the articles had been selected according to title, the
abstracts were analyzed, and articles meeting the eligibility
criteria were read in full. The reviewers compared the stud-
ies and, in case of disagreement, a third reviewer (MAB)
arbitrated. Any disagreements about a study’s eligibility
were decided by a consensus meeting.
Data collection process
Two reviewers extracted the data from eligible studies
independently using a standard form for data extrac-
tion. All analyses were conducted in Review Manager
(RevMan) software (version 5.3; The Nordic Cochrane
Centre, Copenhagen, Denmark).12 The following informa-
tion was extracted: authors; year of publication; study
objective, characteristics of the participants (sex, age,
diagnosis, symptom length); description of the interven-
tion and control groups; description of outcomes (orofacial
pain assessment instruments, pressure pain threshold (PPT)
and pain-free maximum mouth opening (MMO)), type of
comparison, description of the results, follow-up and
studies included and excluded in the meta-analysis. The
data extracted from all included studies are shown in
Table 1.
Risk of bias in individual and across studies
The studies were evaluated individually for their risk of bias.
The risk of bias was assessed using the Cochrane Collabo-
ration risk of bias assessment tool, which rates studies as
high, low or unclear risk of bias.10,13 Two reviewers (CV and
MBA) assessed randomization, allocation, blinding, incom-
plete data outcome, selective reporting and other bias, the
assessment was standardized following the Cochrane Hand-
book for Systematic Reviews of Interventions.10 In case of
any disagreement, it solved by discussion, if the disagree-
ment persists, a third assessor (MAB) arbitrated.
Document downloaded from http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

Effectiveness of dry needling for orofacial pain

BJPT-145; No. of Pages 9

+Model
https://doi.org/10.1016/j.bjpt.2018.08.008
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain

Table 1 Summary of randomized clinical trials included in the review.

Study, year Participants Intervention group Intervention protocol Comparison group Outcome measure Results Follow-up Meta-analysis
Gonzalez-Perez n = 48; 19F; 5M DN lateral LTN: 1 min Methocarbamol; Pain intensity. Pain intensity 28 d 28/70 d
et al., 201520 Age: 18---65 pterygoid. Freq: 1 p/w paracetamol. MMO. (p < 0.001); 70 d
Pain: ≥6 m Duration: 3 w (p = 0.011). MMO
(p > 0.05).
Silva et al., n = 20; 20F Age: DN masseter. LTN: NS DN; lidocaine Pain intensity. PPT. Pain intensity 24 h
201221 NS Pain: NS Freq: 1 injection. (p > 0.05). 7/15 d
PPT (p > 0.05). 21/30 d
Itoh et al., n = 16; 5F; 11M DN masseter, LTN: 30 min Sham DN. Pain intensity. Pain intensity 5/10 w X

ARTICLE IN PRESS
201222 Age: 19---24 temporalis, lateral Freq: 1 p/w Duration: MMO. (p = 0.003). MMO
Pain: ≥6 m pterygoid, DM, SM, 5w (p = 0.236).
SCM, TM.
Diraçoglu n = 52; 45F; 7M DN masseter, LTN: NS Sham DN. Pain intensity. PPT. Pain intensity 10 w
et al., 201216 Age: 18---57 temporalis. Freq: 1 p/w Pain education. MMO. (p = 0.478).
Pain: ≥1 m e ½ Pain education. Duration: 3 w PPT (p < 0.001).
MMO (p = 0.411).
Fernandez n = 12F Age: DN masseter. LTN: NS. Sham DN. Pain intensity. PPT. Pain intensity X
et al., 201017 20---41 Pain: Freq: 1 p/w MMO. (p < 0.001).
≥6 m Duration: 2 w PPT (p < 0.001).
MMO (p < 0.001).
McMillian n = 30F Age: DN masseter; LTN: 1---2 min. G1: Procaine Pain intensity. Pain intensity X
et al., 199718 20---50 Pain: sham procaine Freq: 1 p/w injection; sham PPT. (p > 0.05).
≥3 m injection. Duration: 3 w DN. PPT (p > 0.05)
G2: Sham DN;
sham procaine
injection.
Uemoto et al., n = 21F Age: DN right masseter; LTN: NS G1: Laser Pain intensity. There was no X X
201319 20---52 Pain: NS lidocaine Freq: 3 masseter right PPT. comparison
injection; SOM (72/48/72 h) (do: 4 J/cm2 ); left MMO. between groups.
10’s. (do: 8 J/cm2 ); SOM
10’s.
G2: placebo laser;
SOM 10’s.
m, months; NS, no specified; DM, digastric muscle; SM, splenius muscle; SCM, sternocleidomastoid muscle; TM, trapezius muscle; LTN, length of time of the needle; Freq, frequency; p/,
per; w, week; D, day; do, dose; G, comparison group; SOM, stretching open mouth; PPT, pressure pain threshold; MMO, pain-free mouth opening.

3
 +Model
Document downloaded
ARTICLE IN PRESS
from http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
BJPT-145; No. of Pages 9

4 C. Vier et al.

Thereafter, the Grading of Recommendations, Assess-
ment, Development and Evaluation (GRADE) system was
used to measure the quality of evidence of each out-
come. The GRADE system consists of five items: (1) study
limitations (risk of bias); (2) inconsistency of results (het-
erogeneity); (3) indirectness of evidence; (4) imprecision of
the effect estimates and (5) reporting bias. The quality of
the evidence was classified into four categories: high, mod-
erate, low and very low.14 The assessment were made by
two reviewers (CV and MBA) and if any disagreement were
found, it was discussed, if there was no agreement between
the reviewers, a third reviewer (MAB) arbitrated. The crite-
ria used to downgrade the quality of evidence was based on
informations given by the GRADE system and on the recom-
mendations made by Atkins et al.15 and Balshem et al.14
to the following intervals: (1) short-term follow-up (up
to 3 months), (2) medium-term follow-up (3---6 months),
and (3) long-term follow-up (beyond 6 months). Results
with -values lower than 0.05 were considered statistically
significant. Clinical relevance was determined according to
the effect size: small = MD < 1 (i.e. 1 point in NPRS or 10% of
10-mm VAS), medium = MD < 2 and large = MD ≥ 2.
Meta-analysis
Meta-analysis of data across trials was conducted when the
studies reported the same outcomes and used similar out-
come measures that could be transformed to an equivalent
unit measure. Review Manager (RevMan) software (version
5.3; The Nordic Cochrane Centre, Copenhagen, Denmark)12
was used to conducted the meta-analysis.

Summary measures Heterogeneity of studies

Heterogeneity among studies was reported using the I2
For this systematic review the pain intensity was considered statistic, defined in the Cochrane handbook as follows:
as primary outcome, PPT and pain-free MMO were consid- 0---40% might not be important; 30---60% may represent
ered as secondary outcomes. moderate heterogeneity; 50---90% may represent substantial
heterogeneity; 75---100% represents considerable hetero-
geneity.
Synthesis of results

Data analyses were performed to determine the treatment Results

effects of DN compared to sham therapy or other inter-
ventions. When necessary, the outcome measures were
converted to a 10-point scale of orofacial pain intensity,
Newtons or pounds were converted to kg/cm2 for PPT
and MMO was converted to a 100 mm scale. The mean
differences (MD) and 95% Confidence Interval (CI) were then
computed. Analyses were carried out at 3 assessment points,
with data from the included studies classified according
Study selection
As summarized in Fig. 1, a total of 3889 studies were found
and 428 duplicates were removed. The 3461 remaining stud-
ies were filtered by title and abstract, of which seven
articles were selected for full reading. Thus, seven16---22 arti-
cles met the eligibility criteria and were included in this

Identification [Pubmed 1377; CINAHL 169; Scopus Additional records identified

704;Web science 384, Pro quest through other sources
576;Cochrane 203;Ped no 365; (n = 0)
LILACS 110) TOTAL=3.889

Records after duplicates removed

TOTAL = 3.451

Screening Records screened Records excluded

(n = 3.461) (n = 3.454)

Eligibility Full-text articles assessed

for eligibility
(n = 7)

Included Studies included in

qualitative synthesis
(n = 7)

Studies included in
qualitative synthesis
(meta-analysis)
(n = 5)

Figure 1 Flow diagram of included articles.

Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
 +Modelfrom http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Document downloaded
BJPT-145; No. of Pages 9 ARTICLE IN PRESS
Effectiveness of dry needling for orofacial pain 5

review, although only five16,21 were included in the meta- description of interventions is very common in papers, but
analysis, since the data in two studies19,22 was insufficient. it must be avoided and the researchers should start to use
All authors were contacted by email to clarify questions TIDiER checklist to do not forget any information about their
about their data, although, unfortunately, none responded. interventions.24
All studies assessed pain intensity with the Visual Ana-
logue Scale (VAS)16,18,20---23 or the Numeric Pain Rating Scale
Study characteristics
(NPRS).17 PPT was measured with algometry, although two
studies20,22 did not evaluate this outcome. Pain-free MMO
The studies were published between 1997 and 2015. Their
measurement was performed with a millimeter ruler16,17,20,22
sample sizes ranged from 12 to 52 individuals (pooled
or caliper,19 although two studies18,21 did not assess
n = 199) whose ages ranged from 18 to 65 years. Myofas-
MMO.
cial TMD was diagnosed using the following instruments:
Only five studies16,22 compared DN with sham/placebo.
Research Diagnostic Criteria for Temporomandibular Disor-
DN was also compared with an methocarbamol (380 mg) and
ders (RDC/TMD),17,20,21,23 HELKIMO --- Clinical Dysfunction for
paracetamol (300 mg),20 lidocaine injection21 and procaine
Temporomandibular Disorders Index I e III,22 the Interna-
injection.18 Uemoto et al.,19 who used infrared laser in their
tional Headache Society’s myofascial pain classifications18
control group, did not compare it with DN and were thus
and algometry.16 The duration of orofacial pain symptoms
excluded from the meta-analysis.
ranged from 1½ months to 5 years. Follow-up ranged from
All study characteristics and the results of the individual
24 h to 10 weeks.
studies are shown in Table 1.
The studies involved several types of DN protocols.
The duration of DN treatment was detailed in only three
studies (1---2 min18,20 and 30 min22 ). The response to nee-
dle manipulation was only specified in three studies,17,20,22 Risk of bias within studies
i.e. therapist-verified involuntary local muscle contraction
after TP needling. DN intervention lasted one,21 three,16,18,20 The risk of bias in the included articles was considered high,
four19 or five22 sessions, with one weekly session being the as shown in Fig. 2(A). The main risk of bias was related to
most prevalent frequency.16,20---22 Unfortunately, the poor the blinding of outcome assessment.
Gonzalez-perez et al 2015

A
Fernández-carnero et al
McMillan; Nolan; Kally

Diraçoglu et al 2012
Uemoto et al 2013

Silva et al 2012

Itoh et al 2012

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

B Random sequence generation (selection bias)

Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other bias

0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

Figure 2 Risk of bias summary: review authors’ judgements about each risk of bias item for each included study (A) and about
each risk of bias item presented as percentages across all included studies (B).

Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
 +Model
Document downloaded
ARTICLE IN PRESS
from http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
BJPT-145; No. of Pages 9

6 C. Vier et al.

Risk of bias across studies Synthesis of the results

The risk of bias across studies is shown in Fig. 2(B). Random
sequence generation, allocation concealment and incom-
plete outcome data were the most prevalent risk of bias
across the eligible trials.
Quality of evidence
Quality assessment is shown in Fig. 3. Study quality was
assessed using the GRADE system, which indicated very low
quality with serious or very serious methodological prob-
lems. Due to missing data, it was not possible to use all
the articles to assess any single outcome; at least two were
removed in each case (Fig. 3).
Dry needling vs. sham
Pain intensity. There is very low quality evidence that no
statistically significant difference was found between DN
and sham for short-term orofacial pain (two trials, pooled
n = 70; MD = 0.30; 95% CI = −0.83 to 1.43; I2 = 24%) (Fig. 4A). It
was not possible to conduct a meta-analysis of the medium-
and long-term effects. Other 2 studies22,25 assessed this
outcome but they were not part of meta-analyses due incon-
sistency of data, one of these studies22 finding a significant
reduction in pain ( = 0.003) in the DN group compared to
sham.
Pressure pain threshold. There is very low quality evidence
that DN was better than sham therapy for PPT in the short-
term (three trials, pooled n = 82; MD = 0.56; 95% CI = 0.31 to
0.81; I2 = 55%) (Fig. 4B), however, the effect size in favor

Figure 3 Quality of evidence (GRADE) between Dry Needling versus Sham (A), and Dry Needling versus Other Interventions (B).

Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
 +Modelfrom http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Document downloaded
BJPT-145; No. of Pages 9 ARTICLE IN PRESS
Effectiveness of dry needling for orofacial pain 7

Figure 4 Effect of Dry Needling vs. Sham Therapy on Pain (A), Pressure Pain Threshold (B) and Pain-free Maximum Mouth Opening
(C), and effect of Dry Needling vs. Other Interventions on Pain (D) and Pressure Pain Threshold (E).

of DN was considered small (MD < 1). It was not possible to
conduct a meta-analysis of medium-term and long-term PPT
effects because no study evaluated them. Itoh et al.,22 did
not assess this outcome.
Pain-free maximum mouth opening. There is very low
quality evidence that no between-group difference was
found in short-term pain-free MMO (2 trials, pooled n = 62;
MD = 0.12; 95% CI = −3.04 to 2.80; I2 = 40%) (Fig. 4C). Medium-
and long-term meta-analysis were not possible to be calcu-
lated due any study assessed these follow-ups. Itoh et al.,22
assessed pain-free MMO although they did not find differ-
ence between groups (p > 0.05). McMillan et al.,18 did not
assessed this outcome.
Dry needling vs. other interventions
Pain intensity. There is very low quality evidence that DN
was better than other interventions for short-term pain (2
trials, n = 68; MD = −0.74; 95% CI = −1.25 to −0.22; I2 = 24%)
(Fig. 4D), however, the effect size of the treatment was
considered small (MD < 1). Meta-analysis for medium- and
long-term effects was not possible due to the lack of data.
Another two trials19,21 assessed this outcome, however due
the lack of data, they were not included in the meta-
analysis, Uemoto et al.,19 found an improvement in pain
intensity after DN (p = 0.03), nonetheless Silva et al.,21 did
not find significant improvement in this outcome (p > 0.05).
Pressure pain threshold. There is very low quality evi-
dence that there was no statistically significant difference
between DN and other interventions for short-term PPT
(two trials, pooled n = 36; MD = −0.08; 95% CI = −0.27 to
0.12; I2 = 0%) (Fig. 4E). Meta-analysis was not performed
for medium- or long-term effects due to the lack of data
on these time-points. One trial19 also assessed PPT but
it was not included in the meta-analysis due to the lack
of data. Gonzalez-Perez et al.,20 did not assessed this
outcome.
Pain-free maximum mouth opening. Meta-analysis of DN
and other interventions in the short-term, medium-term and
long-term for pain-free MMO was impossible. One study20
assessed this outcome but due lack of data it was impossible

Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
 +Model
Document downloaded
ARTICLE IN PRESS
from http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
BJPT-145; No. of Pages 9
8 C. Vier et al.
to run a meta-analysis. The quality evidence of this outcome
was also classify as ‘‘very low quality’’ by the GRADE.
Discussion
This systematic review and meta-analysis of 7 trials (pooled
n = 199 individuals) investigated the effectiveness of DN
compared to sham therapy,16,19---22 other interventions (lido-
caine injection,20---22 procaine injection)18 or combination
drug therapy (methocarbamol and paracetamol)20 for orofa-
cial pain, PPT, disability and pain-free MMO in subjects with
TMD-related myofascial pain. We found very-low-quality evi-
dence that: (1) compared with sham therapy, DN increases
PPT in the short-term, and (2) DN is more effective than
other interventions at decreasing pain intensity.
Nevertheless, meta-analysis regarding DN and other
interventions could only be applied at short-term follow
ups. No meta-analysis was possible for disability and pain-
free MMO due to insufficient data. No statistically significant
differences were found between DN and sham therapy in
the short-term for pain or pain-free MMO. When DN was
compared with other interventions for PPT, the same result
was found. However, significant differences were found for
PPT when DN was compared with sham therapy and for
pain intensity when DN was compared with other interven-
tions. These results suggest that DN increases PPT compared
with sham therapy and decreases pain intensity compared
to other interventions (lidocaine injection and combination
drug therapy (methocarbamol and paracetamol)). Finally, no
meta-analysis could be conducted for medium- or long-term
effects in any outcome because none study assessed medium
or long-term follow-up.
Studies in this review that used sham therapy applied
needles near the TP site. There is evidence that DN
applied in the muscle belly or in the subcutaneous region
of the fascia has effects on pain modulation in myofas-
cial syndrome.26---28 However, it is not clear whether DN is
superior to placebo.7 Similarly, studies using minimal/sham
acupuncture procedures also suggest that sham acupuncture
needles evoke a physiological response.29,30 Another aspect
that may explain why DN did not significantly decrease
pain intensity compared to sham therapy may be the poor
methodological quality of the included studies and their het-
erogeneity of protocols.16,18
The literature reports greater efficacy for laser therapy
than dry needling. It has been suggested that laser ther-
apy causes improvement in microcirculation, which would
increase the oxygen supply to hypoxic cells and help remove
cell metabolism waste products, thus breaking the vicious
cycle of pain, muscle spasm and further pain. While laser
therapy is the method of choice for patients with a fear
of needles and healthcare professionals inexperienced with
dry needling techniques, further controlled studies are still
needed to conclusively demonstrate the greater efficacy of
this method.23
Moreover, all but one of the studies recruited patients
with chronic orofacial pain. Although it is known that treat-
ing chronic orofacial pain is complex and a biopsychosocial
approach is necessary, only one study applied pain education
in addition to DN. A systematic review on musculoskeletal
conditions31 and another on myofascial TPs32 found similar
Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
results about pain intensity and PPT, and both studies also
found low-quality-evidence in their included studies.
Conclusion
The studies included in this systematic review suggest that
DN is better than sham therapy for PPT and better than other
interventions for pain intensity in the short-term. Neverthe-
less, due to the very low quality of evidence, DN cannot be
strongly recommended over sham therapy or other interven-
tions.
To date, there is insufficient data to draw strong conclu-
sions about DN for the treatment of orofacial pain associated
with TMD. Randomized controlled trials of low risk of bias
are strongly needed.
Conflicts of interest
Marcos Lisboa Neves and Marina Barbosa de Almeida use
dry needling therapy in clinical practice and provide post-
graduate training programs. The others authors declare no
conflicts of interest.
Acknowledgements
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
References
1. Orofacial Pain: Guidelines for Assessment, Diagnosis, and
Management. 5th ed. Chicago: Quintessence Publishing Co,
Inc; 2013.
2. Gonçalves DAdG, Dal Fabbro AL, Campos JADB, Bigal
ME, Speciali JG. Symptoms of temporomandibular disor-
ders in the population: an epidemiological study. J Oro-
fac Pain. 2010;24(3):270---278. http://www.ncbi.nlm.nih.gov/
pubmed/20664828 Accessed 14.05.18.
3. Slade GD, Bair E, Greenspan JD, et al. Signs and Symptoms
of First-Onset TMD and Sociodemographic Predictors of Its
Development: The OPPERA Prospective Cohort Study; 2013,
http://dx.doi.org/10.1016/j.jpain.2013.07.014.
4. Kalichman L, Vulfsons S. Dry needling in the manage-
ment of musculoskeletal pain. J Am Board Fam Med.
2010;23(5):640---646, http://dx.doi.org/10.3122/jabfm.2010.
05.090296.
5. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The
Trigger Point Manual. Baltimore: Williams & Wilkins; 1983.
6. Zhuang X, Tan S, Huang Q. Understanding of myofascial trigger
points. Chin Med J (Engl). 2014;127(24):4271---4277.
7. Cummings TM, White AR. Needling therapies in the mana-
gement of myofascial trigger point pain: a systematic
review. Arch Phys Med Rehabil. 2001;82(7):986---992,
http://dx.doi.org/10.1053/apmr.2001.24023.
8. Romero-Reyes M, Uyanik JM. Orofacial pain management:
current perspectives. J Pain Res. 2014;99(February),
http://dx.doi.org/10.2147/JPR.S37593.
9. Effectiveness of dry needling for upper-quarter myofascial
pain: a systematic review and meta-analysis. J Orthop Sport
Phys Ther. 2013;43(9):620---634.
10. Cochrane Handbook for Systematic Reviews of Interventions.
Chichester, England; Hoboken, NJ: Wiley-Blackwell; 2008.
 +Modelfrom http://www.elsevier.es, day 07/11/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Document downloaded
BJPT-145; No. of Pages 9 ARTICLE IN PRESS
Effectiveness of dry needling for orofacial pain
11. Mancini MC, Cardoso JR, Sampaio RF, et al. Tutorial for
writing systematic reviews for the Brazilian Journal of Phys-
ical Therapy (BJPT). Braz J Phys Ther. 2014;18(6):471---480,
http://dx.doi.org/10.1590/bjpt-rbf.2014.0077.
12. Review Manager, (RevMan) [Computer program] Version 5.3.
2014.
13. Higgins JPT, Altman DG, Gotzsche PC, et al. The Cochrane
Collaboration’s tool for assessing risk of bias in randomised
trials. BMJ. 2011;343(October (2)):d5928, http://dx.doi.org/
10.1136/bmj.d5928.
14. Balshem H, Helfand M, Schünemann HJ, et al. GRADE
guidelines: 3 Rating the quality of evidence. J Clin
Epidemiol. 2011;64(4):401---406, http://dx.doi.org/10.1016/
j.jclinepi.2010.07.015.
15. Atkins D, Best D, Briss PA, et al. Grading quality of evidence
and strength of recommendations. BMJ. 2004;328(7454):1490,
http://dx.doi.org/10.1136/bmj.328.7454.1490.
16. Dıraçoğlu D, Vural M, Karan A, Aksoy C. Effectiveness of dry
needling for the treatment of temporomandibular myofas-
cial pain: a double-blind, randomized, placebo controlled
study. J Back Musculoskelet Rehabil. 2012;25(4):285---290,
http://dx.doi.org/10.3233/BMR-2012-0338.
17. Fernandez-Carnero J, La Touche R, Ortega-Santiago R, et al.
Short-term effects of dry needling of active myofascial trigger
points in the masseter muscle in patients with temporo-
mandibular disorders. J Orofac Pain. 2010;24(1):106---112.
18. McMillan AS, Nolan A, Kelly PJ. The efficacy of dry
needling and procaine in the treatment of myofascial pain
in the jaw muscles. J Orofac Pain. 1997;11(4):307---314.
http://www.ncbi.nlm.nih.gov/pubmed/9656906.
19. Uemoto L, Garcia MAC, Gouvêa CVD, Vilella OV, Alfaya
TA. Laser therapy and needling in myofascial trig-
ger point deactivation. J Oral Sci. 2013;55(2):175---181.
http://www.ncbi.nlm.nih.gov/pubmed/23748458.
20. Gonzalez-Perez L, Infante-Cossio P, Granados-Nunez M, Urresti-
Lopez F, Lopez-Martos R, Ruiz-Canela-Mendez P. Deep dry
needling of trigger points located in the lateral pterygoid
muscle: efficacy and safety of treatment for management
of myofascial pain and temporomandibular dysfunction. Med
Oral Patol Oral y Cir Bucal. 2015;(January):e326---e333,
http://dx.doi.org/10.4317/medoral.20384.
21. Silva ROFd, Conti PCR, Araújo CdRP, Silva RdS. Eval-
uation of dry needling and 0.5% lidocaine injection
therapies in myofascial pain trigger points in mastica-
tory muscles. Dental Press J Orthod. 2012;17(2):113---118,
http://dx.doi.org/10.1590/S2176-94512012000200020.
Please cite this article in press as: Vier C, et al. The effectiveness of dry needling for patients with orofacial pain
associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2018,
https://doi.org/10.1016/j.bjpt.2018.08.008
9
22. Itoh K, Asai S, Ohyabu H, Imai K, Kitakoji H. Effects of
trigger point acupuncture treatment on temporomandibular
disorders: a preliminary randomized clinical trial. J Acupunct
Meridian Stud. 2012;5(2):57---62, http://dx.doi.org/10.1016/
j.jams.2012.01.013.
23. Uemoto L, de Azevedo RN, Alfaya TA, Jardim Reis RN,
Depes de Gouvea CV, Cavalcanti Garcia MA. Myofascial
trigger point therapy: laser therapy and dry needling.
Curr Pain Headache Rep. 2013;17(9):357, http://dx.doi.org/
10.1007/s11916-013-0357-4.
24. Yamato T, Maher C, Saragiotto B, et al. The TIDieR
checklist will benefit the physical therapy profession.
Braz J Phys Ther. 2016;20(3):191---193, http://dx.doi.org/
10.1590/bjpt-rbf.2014.0182.
25. Fernández-Carnero J, La Touche R, Ortega-Santiago R, et al.
Short-term effects of dry needling of active myofascial trigger
points in the masseter muscle in patients with temporo-
mandibular disorders. J Orofac Pain. 2010;24(1):106---112.
http://www.ncbi.nlm.nih.gov/pubmed/20213036.
26. Short-term improvement following dry needle stimula-
tion of tender points in fibromyalgia. Rheumatol Int.
2014;34(6):861---866.
27. Lewit K. The needle effect in the relief of myofascial pain.
Pain. 1979;6(1):83---90.
28. Neal BS, Longbottom J. Is there a role for acupunc-
ture in the treatment of tendinopathy? Acupunct
Med. 2012;30(4):346---349, http://dx.doi.org/10.1136/
acupmed-2012-010208.
29. Lundeberg T, Lund I, Sing A, Näslund J. Is placebo acupuncture
what it is intended to be? Evid-Based Complement Altern Med.
2011;2011:1---5, http://dx.doi.org/10.1093/ecam/nep049.
30. White AR, Filshie J, Cummings TM. Clinical trials of
acupuncture: consensus recommendations for optimal
treatment, sham controls and blinding. Complement
Ther Med. 2001;9(4):237---245, http://dx.doi.org/10.1054/
ctim.2001.0489.
31. Gattie E, Cleland JA, Snodgrass S. The effectiveness of
trigger point dry needling for musculoskeletal conditions
by physical therapists: a systematic review and meta-
analysis. J Orthop Sport Phys Ther. 2017;47(3):133---149,
http://dx.doi.org/10.2519/jospt.2017.7096.
32. Espejo-Antúnez L, Tejeda JF-H, Albornoz-Cabello M,
et al. Dry needling in the management of myofascial
trigger points: a systematic review of randomized con-
trolled trials. Complement Ther Med. 2017;33:46---57,
http://dx.doi.org/10.1016/j.ctim.2017.06.003.